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Mendoza, T., Mindanao, A., Miranda, M., Molina, M., Monzon, J., Morales, A., Musni, M., Nallas, A., Naval, A., Nepomuceno, J., Nerpiol, C., Ng, C., Ng,

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Presentation on theme: "Mendoza, T., Mindanao, A., Miranda, M., Molina, M., Monzon, J., Morales, A., Musni, M., Nallas, A., Naval, A., Nepomuceno, J., Nerpiol, C., Ng, C., Ng,"— Presentation transcript:

1 Mendoza, T., Mindanao, A., Miranda, M., Molina, M., Monzon, J., Morales, A., Musni, M., Nallas, A., Naval, A., Nepomuceno, J., Nerpiol, C., Ng, C., Ng, P., Niere, J., Millicent Tan Ong, MD Helmar Soldevilla, MD 3C-MED Medicine II –Module 4 Clinical Case: Psoriasis Psoriatic Arthritis Cellulitis

2 OBJECTIVES Present a case of a 28 y/o male with Psoriatic Arthritis (PsA) Differential Diagnoses Pathophysiology of PsA Approach to a Patient with PsA Complications, Outcome and Prognosis of PsA

3 MEDICAL HISTORY 28 year old male, catholic, married, tricycle driver, residing in Caloocan City Chief Complaint:

4 History of Present Illness 7 Yrs PTA Diagnosed with Psoriasis based on the following: Flaky white scales on the scalp Pustules, papules  plaques topped with scales at the back, trunk, upper and lower extremities and his face Punch biopsy: Psoriasis Rx: Psoralen + Ultraviolet A (PUVA) therapy Methotrexate (2.5mg) at 12 hr intervals for three doses each week Dermovate (unrecalled dose) with Petroleum Jelly and LCD Hydroxizine (Iterax) for pruritus 3x/day prn Full resolution of skin lesions Diagnosed with Psoriasis based on the following: Flaky white scales on the scalp Pustules, papules  plaques topped with scales at the back, trunk, upper and lower extremities and his face Punch biopsy: Psoriasis Rx: Psoralen + Ultraviolet A (PUVA) therapy Methotrexate (2.5mg) at 12 hr intervals for three doses each week Dermovate (unrecalled dose) with Petroleum Jelly and LCD Hydroxizine (Iterax) for pruritus 3x/day prn Full resolution of skin lesions 2 Yrs PTA Recurrence of skin lesions Pain and swelling of all the digits of both hands Rx: Naproxen (550mg/tab) BID prn Asymmetric oligoarthritis  polyarthritis involving the DIPs and PIPs of both hands, BKJ Consult to Rheumatologist Rx: Celecoxib (unrecalled dose) Recurrence of skin lesions Pain and swelling of all the digits of both hands Rx: Naproxen (550mg/tab) BID prn Asymmetric oligoarthritis  polyarthritis involving the DIPs and PIPs of both hands, BKJ Consult to Rheumatologist Rx: Celecoxib (unrecalled dose)

5 1 month PTA persistent swelling on BKJ with↑ pain (VAS 9/10) 1 week PTA Non-radiating pain (VAS 7/10) on the low back, hips, and BAJ More difficulty in ambulation Non-radiating pain (VAS 7/10) on the low back, hips, and BAJ More difficulty in ambulation 5 days PTA Consult to Orthopedic Surgeon; diagnosed with BKJ effusion & advised arthrocentesis 4 days PTA Undocumented fever temporarily relieved by Cefuroxime and Paracetamol (unrecalled dose) Consult at FEU Hospital: (X-Ray of leg: soft tissue swelling) Advised admission but refused due to financial constraints Transferred to USTH for further evaluation & management Undocumented fever temporarily relieved by Cefuroxime and Paracetamol (unrecalled dose) Consult at FEU Hospital: (X-Ray of leg: soft tissue swelling) Advised admission but refused due to financial constraints Transferred to USTH for further evaluation & management ADMISSION 1 Yr PTA Pain and swelling on both knee joints (BKJ)  limping Relieved by various unrecalled NSAIDs Pain and swelling on both knee joints (BKJ)  limping Relieved by various unrecalled NSAIDs

6 Past Medical History (-) DM (-) HPN (-) Joint surgery (-) history of trauma (-) Allergy Diagnosed with dengue fever (2 nd year high school) Excision of cyst at the back (2007)

7 Family History (+) Myocardial Infarction – father (+) DM – father (-) HPN (-) stroke (-) Psoriasis (-) Cancer (-) Arthritides

8 Personal & Social History Smoker: 0.6 pack years Occasional Alcoholic Beverage Drinker Denies Illicit Drug Use 3 past sexual partners, all protected Tricycle driver No history of travel outside manila

9 Review of Systems No wt. loss, no loss of appetite No hearing loss, no nasal congestion, no cough No dyspnea, orthopnea, cyanosis No chest pain, palpitations No abdominal pain, diarrhea, constipation No dysuria, frequency, change in character of urine

10 PHYSICAL EXAMINATION General Survey Conscious, coherent, oriented as to time, place and person, not in cardio-respiratory distress Vital Signs BP 120/70 mmHg Wt: 70 kgs PR 83 bpm Ht: 1.62 m RR 20 cpm BMI : 26.5 kg/m 2 T° = 36.6 °C Skin (+) generalized erythema w/ multiple well- to ill-defined papules and plaques topped with whitish scales over the scalp, trunk and extremities (+) onychodystrophy, nail pitting, oil spots of all nails of the hands and feet

11 HEENT Pink palpebral conjunctivae, anicteric sclerae, no naso- aural discharge, no tragal tenderness, moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged Neck Supple neck, trachea midline, no palpable cervical lymph nodes, thyroid gland not enlarged Cardiovascular Adynamic precordium, AB at 5 th LICS, MCL; no murmurs All pulses full and equal Respiratory Symmetric chest expansion, no retractions, clear breath sounds on all lung fields, no crackles, no wheezes Abdomen Flat abdomen, NABS, soft, nontender, no masses

12 Musculoskeletal Hand (+) sausage-shaped 2 nd and 4 th digit of the right hand & 4 th & 5 th digits of the (L) hand (+) Flexion contracture of the DIPs of the 2 nd, 4 th and 5 th digits of the (R) hand & 5 th digit of the (L) hand (+) tender, swollen, erythematous DIPs and PIPs of the 2 nd, 4 th and 5 th digits of the ® hand and DIP of the 4 th and 5 th digit of the (L) hand All Active Range of Motion (AROM) of bilateral hands are within normal limits EXCEPT: (L) hand (R) hand (R )DIPPIP 2 nd digit45-45°0-30° 4 th digit45-45°0-45° 5 th digit30-30°0-50° Passive Range of Motion (PROM) not assessed due to tenderness of the affected joints (L)DIPPIP 4 th digit0-45° 5 th digit50-50°0-40°

13 Landmark: Medial Tibial Plateau RIGHTLEFTDIFFERENCE 3 inches40.5 cm38 cm2.5 cm 6 inches40.5 cm37.5 cm3 cm 9 inches30.5 cm28 cm2.5 cm BKJ (+) swelling, warmth, tenderness PROM within normal limits Legs swollen, warm, tender, erythematous (R) leg Limb Girth Measurement AROM(R)(L) BKJ0-100°0-125°

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15 SALIENT FEATURES 28 y/o male History of Psoriasis Asymmetric oligoarthritis  polyarthritis of the affected DIPs and PIPs of both hands, BKJ, and (BAJ) (+) Flexion contracture of the DIPs of the affected digits (+) sausage-shaped digits Limited AROM of the affected joints BKJ effusion swollen, warm, tender, erythematous (R) leg Undocumented fever Pertinent (+)

16 SALIENT FEATURES No history of morning stiffness of joints No hx of bacterial infection or serious chronic illness No hx of infection before onset of arthritis No family history of arthritides Pertinent (-)

17 OBJECTIVES Present a case of a 28 y/o male with Psoriatic Arthritis (PsA) Differential Diagnoses Pathophysiology of PsA Approach to a Patient with PsA Complications, Outcome and Prognosis of PsA

18 THANK YOU


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